Our future health depends on the success of hospital medicine

Over the past few years I have talked with many hospitalists. I know many hospitalist leaders and have many hard working hospitalists.

Most classic general internists have viewed the hospitalist movement with skepticism. Many outpatient internists express jealousy over the salaries and work hours of most hospitalists.

But here is what most non-hospitalists do not understand. In most hospitals in this country hospitalists are treated as second class citizens by their fellow physicians. Most other physicians have no respect for hospitalists.

They are happy to have hospitalists provide care for their patients. After all, hospitalists dictate H&P’s and DC summaries. Hospitalists become skilled at social work interaction. Hospitalists take all the calls that other physicians dislike.

But too often subspecialists, surgeons and others view hospitalists as advanced residents – physicians they can abuse without recourse. Too often they have no understanding of the hospitalist job.

So we have an interesting problem, hospitalists make a fair wage and have call responsibilities that make quality of life excellent. Hospitalists improve patient care and the lives of other physicians, yet they get no respect.

I suspect that over time at many hospitals this respect problem will dissipate, but hospital medicine does suffer from serious growing pains. The demand for hospitalists is so great that many hospitals are happy to hire less well trained physicians.

The hospitalist job is a difficult one. They care for approximately 17 patients each day. Their patients are complex and many have undesirable social situations. Hopsitalists are doing important work on safety and quality, yet they too often get no respect.

I believe this is the hospitalist’s challenge this decade. The field should consolidate and better define best practices.

Hospital medicine has an image problem with many patients and many physicians. If hospitalists can gain respect from their physician peers, then patient respect will follow.

Whether you have favored the hospitalist movement or not, one should no longer lament its growth. We must all join to make hospital medicine successful. Our own future health care may depend on their success.

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http://drsamgirgis.com Dr Sam Girgis

I work as a hospitalist in New York City. Our group of 13 hospitatlists runs the entire hospital and without us, the hospital would have to close down. We are the core of the engine that runs our hospital. I welcome the view that we are advanced residents… if we are the core of the hospital engine than our medical residents are the nuts and bolts. And I have never felt that we are not respected by any of our colleagues.

I am lucky to have hospitalists in my area. I still see my own office patients, but the unassigned ER patients go to the hospitalists. On ER call I used to get stuck with 4-8 admission in 24 hours with only 1-2 Medicare and the rest self pay/no pay or Medicaid. No more drug ODs, alcoholics, or against medical advice letters from drug seakers in the middle of the night, thanks to the hospitalists. I also get fewer middle of the night calls, as I try to tuck in my quality patients. Being the hospitalist on call, as per their stories, reminds me of being in residency again. I’m not sure how the hospitalists make money, but the hospitals must have them to see the unassigned patients.

Louis R. Zako, M.D.

Although I am somewhat sympathetic with the curren tack of respect hospitalists currently enjoy, as a retired family physician, I and thousands of family physicians have endured similar lack of respect for decades.

http://www.BocaConciergeDoc.com Steven Reznick MD

We have a new hospitalist program at my primary community hospital. The first program failed when administration fired the group who few were happy with. I never understood why? The hospitalist role is to admit patients through the ER who do not have a doctor and require admission. Our new hospitalists often do not come in to see the patients in the evening but take the word of the ER staff about their status and admit the patient over the phone. They see the patient within twelve hours. While I am clearly a dinosaur in the evolving world of medicine, my associate and I have one coverage rule for the last 30 years, if the patient is sick enough to require admission they are sick enough to be seen when called. There have been many sleepless nights followed by challenging days but at the end of the day when we look ourselves in the mirror we have done what we believe is best for the patient. Our hospitalists will have to earn our respect by their actions not by blogs on KevinMD.
There is no room for bullying hospitalists or treating any of our MD colleagues as second class citizens, medical students or house officers. On the other hand I do believe the hospitalist movement is a creation of the insurer/employer/hospital administration complex to attempt to keep the institution in the black. What it will do is erode the skills of generalists and dumb down general internal medicine and family practice. The ACP went along with it because they are controlled by medical subspecialists and had no way to enhance the reimbursement and life of internists as per their own White Paper on the subject back in the late 1980’s and early 1990’s.
I see hospitalists working short intense careers and then burning out because they get few of the emotional rewards that longitudinal brings. The argument about who provides better care hospitalists or their usual doctor will never be answered equivocally. There will be beacons of excellence in each domain and mediocrity as well

Natalie Sera

Well, I was left to suffer for days, TWICE, because hospitalists, looking at my age (62), and slight overweight, decided I was a Type 2 diabetic and withheld insulin from me. The decided to use a sliding scale of insulin for corrections before meals only, and left me to sit for hours with blood glucose in the 400’s because it wasn’t time for the next meal yet, and they not only wouldn’t give me a timely correction, but wouldn’t give me extra insulin to cover the meal. And I had no insulin to cover me at night, either. In the hospital, where I had been admitted in a diabetic coma, the CDE finally, after 3 days, convinced the hospitalist that I needed to be treated as a Type 1, with a basal/bolus regimen, but when they discharged me to a rehabilitation hospital, because my BGs were still quite high, my records apparently didn’t come with me, and it was right back to square one, and it took 3 days to corner the hospitalist and get him to give me basal/bolus. I attribute this to the hospitalists not knowing ME and my diabetic history, whereas my own doctor would have known. Whereas I SHOULD have recovered in a week, their incompetence meant I was hospitalized for 4 weeks — waste of money and much agony. I would rather NEVER see a hospitalist again, but it’s not like I have a choice!

SueCz

Thank you Dr Resnik. I admire the standard of care you and your associate lived by for 30 yrs. I so admire and respect my PCP and endocrinologist that I have been seeing on a regular bases for years. I feel they have a sense of who I am and life choices I would make. I feel so sad that @ a time I need them most, they are not any part of my care. I hesitate to post this tale of woe, but I feel it demonstrates how much MY physicians were needed. Last Summer I had 80% of my Liver removed for an unusual slow growing cancer. One of many complications was a sub-diaphragmatic abscess. Infectious disease specialist told me the team felt drainage and long term IV antibiotics imperative, but he said surgeon did not agree, no one from the surgical team came nor the next day @ 6:00 am rounds said a word. Infectious disease returned and spent a lot of time with me. I knew I was VERY sick and VERY scared, the culture was Staph. I agreed and Interventional Radiology did the procedure. No sign of my surgical team until 5:am next day when a new to me surgical resident came to discuss my discharge. I told him to put the light on, I have 3 chest tubes(pneumothorax with procedure 10 hrs previous !), abd drains, neck line, HUGE incision,temp 101*. He said no worry, visiting nurses can handle all. I asked him to leave my room and not come back. He knew NOTHING about me except that I was 5 days postop and he was house cleaning before the weekend. This is but one experience of several real nightmares. I truly was so sad, wondering if my PCP had any idea what was happening to me. I knew she would not have tolerated the medicine being practiced. I never saw any physician ,other then Infectious disease, long enough to get a sense of who they were. I certainly was not a person to them.

My point of view comes from several personal experiences recently, from previous colleagues, and several friends of my children(2) who are brand new hospitalist.
The experience in my local area is Hospitalist take over your care from the moment of admission.Local PCPs no longer go near the hospital, the Hospitalist Oncologist covers, and whoever is covering the hospital for the day is who you get for procedures. No choices, unless admitted as private surgical patient, that surgeon does do the procedure, but then all care is managed by residents and hospitalist. The surgeon may/may not drop by during your stay. They may be orchestrating your care via email or phone or “rounds”, but there is absolutely no sense of “my doctor” or that anyone is watching over you. Hospitalists change shift and your care plan does too. Here they work 12hr shifts, one week on, one week off. They are required to meet and round an hour before their shift. I don’t think the week they are on is an envious lifestyle. There is MUCH discussion about this within my community. Neighbors talk about their experiences and want to understand how to work within the system. My healthy mid-twenties kids have no medical contact and can’t believe it can be so, those of us in our early sixties are terrified.
Hospitalists appeared shortly prior to my retirement.
And I’m sorry, but what physician in his right mind, who has been in an established practice for 25-30yrs in Kansas suddenly gets a yearning to learn a new field of practice in Boston? At that time, the first group hired, this was the “average ” profile of our hospitalist. I am retired from Anesthesia now, but I hear there is an influx of young, bright physicians into the hospitalists program .I know the 2 young men I know are passionate and eager to make a difference. I am really glad to hear that, but apparently the style of practice has not yet begun to change. I sincerely hope physicians like yourself and those who care enough to blog and discuss these changes can hang in and influence the next decade.
Thank you.

http://healthasahumanright.wordpress.com Health as a Human Right

I whole heartedly disagree that hospitalists perform important work. I find the profession needless and not in the best interest of patient care. I am more in line with Dr. Reznick that these physicians should not be disrespected, but in truth understand why they are. Hospitalists as a profession are not to be lauded until they can prove their worth.

The idea of hospitalists medicine was in theory and a good one – to lighten the load of the PCP and have someone familiar with the hospital to navigate a patient through their stay while being more readily available. I am respectful of the fact that in sum hospitalists decrease lengths of hospital stays and cut hospital costs. And that some studies have shown that care by hospitalists means fewer readmissions and lower mortality rates. I also would say their place is needed when there are patients without PCPs or out of town. Still, i would disagree with the notion that this is not in sacrifice of quality of care.

Here are my concerns – patients being unfamiliar with a care provider, the discontinuity of care, the lack of responsibility for patients, and how it fits in with recent changes in medical care.

Patients develop relationships with their primary care doctors over time – they don’t and cannot develop relationships with their hospitalists. In a hospital, patients are at their sickest, they are vulnerable and exposed, and then without notice a doctor comes in that they’ve never met. How can they trust this person to tell them their personal history? How can the hospitalists pick up on facts the patient may leave out because of lack of trust or just forgetting.

In the absence of familiarity, continuity of care is crucial. Still, doctors aren’t great at it. I’ve not yet heard of a doctor that gets and looks over a patient’s records thoroughly before talking to them – they have no idea of that patient’s medical history even if it’s available electronically. I don’t really think they talk to each other…ever. This is troubling to me. Your PCP knows your medical history – your allergies, your home life, your stresses, your cultural preferences, your diseases and family history. When you’re in the hospital you want someone who knows all of these things – especially when you are most vulnerable. While the hospitalist can get quite a lot of this information, likely he or she will miss out on a lot. Perhaps you don’t think things like stress and home life are all that relevant to your hospital care, but often those issues contribute to your health and even your likelihood to follow a treatment regimen. Not having this continuity of care can disrupt your treatment. While the studies are showing that outcomes are about the same, I am not convinced. Particularly when there is much ruckus about the meaningful use requirements of HIT that are not being met.

Furthermore, even before you are admitted to the hospital, usually you go through the emergency department and are seen by a doctor there – yet another transfer of care that could lead to gaps in information. Theoretically transfer from one department to another should be seemless, I assure it is not for most patients. When you’re not feeling well, and if you don’t have a friend or family member to be your patient advocate, who knows you and your history, there’s no one to fill in those gaps.

When patient care is disjointed, responsibility for the patient can become murky. It seems like the line would be as follows: when inpatient, hospitalist is responsible; when outpatient, PCP is responsible. But liability issues arise because it’s not so simple. Doctors are responsible for follow-up care. Thus when discharged from a hospital should the hospitalist follow up? Yes. But your PCP should too. Without very close coordination of care, this can become tricky leading to miscommunications between the doctors, to you, to your family or others throughout your care in and out of the hospital.

About 80% of adverse events in hospitals involve communication problems between healthcare professionals, mostly from handoffs. Poor communication may also mean redundant tests, prolonged hospitalizations or readmissions. This includes communications between PCPs and hospitalists and between hospitalists when care is transferred during a patient”s stay. Miscommunication is easy – we all know doctors have the worst handwriting, plus with complex medical problems details can be missed, and what about doctors simply being in a rush and not really taking the time to communicate to each other? With all the physicians involved there is ample room for error.

In a silly analogous way, I feel like this sort of medicine is playing “hot potato” with the patient – passing the patient around from provider to provider for short bursts of care. In the end, the PCP is “stuck” with you but what if someone drops you in between? Who has responsibility throughout it all, with your life in so many hands? It troubles me that the responsibility is so spread out and there are many opportunities for things to get messed up.

(On a side note – quality measurements are a bit more difficult to attribute to each doctor. Is the hospitalist judged on how the patient fares after discharge or if rehospitalized? Is the PCP judge on the patient’s health while in the hospital or the patients health when following directions of a hospitalists upon discharge?)

There are other issues of liability that come with issues of responsibility for the patient – including issues of referral to a competent hospitalist physician by a PCP, scope of care issues, diagnosis issues, and patient abandonment. There are issues that arise from tests not being preformed after discharge or test results not being shared before or after hospitalization. Further issues arise in the way lawyers think about traditional liability in the hospital – particularly as hospitalists employees of the hospital. And then the ethical issue of a patient’s right to choose his or her provider.

Beyond liability, hospitalists fit in with interesting changes in medical care that I’m still hesitant to accept. More and more physicians are choosing to be employed by hospitals instead of going into private practice as primary care physicians. This is great for the doctors who have a steady salary, fewer working hours, and less financial risk. But this also means that there are fewer PCPs in the community, and we already have a shortage of PCPs.

Doctors working fewer hours is also an interesting trend. I remember the horror stories of the shifts my father used to work as a resident – 100 + hour weeks. That has drastically changed. But studies haven’t shown that doctors are actually performing better when they work fewer hours. In the end, fewer hours whether as a resident whose hours are capped or as a hospitalist with set hours means more hand-offs between physicians. You already know my misgivings about these hand-offs.

One more trend that makes me worry is the rise in hospitalists as we start to develop Accountable Care Organizations (ACOs). I don’t want to go into too much detail here but I would just say that I have serious concerns over the conglomeration of hospitals and physicians. ACO’s will theoretically result in hospitals and doctors working together to work toward better outcomes and reduced costs. It’s complicated but in the end it could mean many hospitals buying physician practices – leading to a more corporate medical care structure in my view. It shouldn’t, but could limit choices for care. And with more doctors employed by hospitals, as hospitals utilize more hospitalists, it just seems to me that all care will soon be centralized in a for-profit health care system run by huge organizations – the implications of which I am not sure I can fathom or would like.

On the whole, while I see the benefits of hospitalists, I still can’t quite accept them as better care providers for hospitalized patients considering legal, ethical, and other issues. I do not accept them nor do I think this post seriously defends them in a way that might change my mind.

http://healthasahumanright.wordpress.com Health as a Human Right

@Natalie Sera – you make my point precisely. Coordination of care drops and you have someone who doesn’t know your medical history. I empathize with your position as I have been there myself. I have yet to meet hospital staff – nurses or doctors who know how to treat Type 1 and this is particularly scary when your health is poor enough to be in a hospital in the first place.

But as you said – what choice do you have? All the more troubling – doctors seem to be supporting this idea that hospitalists are good if not better for care. The discussion is one sided and lacking in any real experience for what it is like as a patient.

SueCz

Thank you, thank you, thank you! Had I seen this reply before I posted mine, I would not have posted. You said all so much better then I could have. You covered all my thoughts .

Medtranscription

Fortunately I know hospitalists only via transcribing. I have 35 years of experience. Currently I work with two hospitals. Hospitalists are some of the worst dictators I have encountered. I think the ESLs must have a hard time with their native language, let alone ours. But speech impediments, lack of knowledge of sentence structure and grammar is abundant in English speaking as well as ESLs hospitalists. Drugs are not clearly understood; they can’t pronounce them but don’t bother to spell them. Fortunately I usually have access to the chart to find the lab results and medications, but not always, and many of my peers don’t have this “luxury”. Hopefully the chart is correct, but many times there is a discrepancy between what is dictated and what the chart says. Now we have hospitalist PA’s dictating, who are even worse. It is hard for me to understand in this age of the “electronic medical” record how a hospitalist report with multiple blanks of key findings, drugs (admission and discharge), instructions and lab work, etc. is progress OR safe.

http://twitter.com/workflowdx Mark H. Davis

I believe this article is unfortunately and erroneously titled. The issue at-hand is whether the hospitalist boon is a bane or a benefit to the quality of hospital care. While we can debate that question eternally, the title makes a different claim — that our future health is dependent upon the hospitals. Not to disparage the hospitals — I’ve worked in a hospital system myself — but I take a different view. I believe the “front lines” of care — the family practices, pediatricians, clinics and others — can have a much greater impact on our long-term health, first by improving our wellness and then by making hospital care less necessary. By keeping patients out of the hospital, these front lines can drastically reduce costs and the compounding effects of secondary infections, falls, errors, accidents, etc.. If we do the job on the front lines, we have potential to reduce demand downstream in our health system and to produce a much healthier nation. These preventative practitioners should not be overlooked or undersold.